Information Collection

Coccidioidomycosis Case Report Form

IC 265998 under ICR 202402-0920-008 · OMB 0920-1385.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1385 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Coccidioidomycosis Case Report Form	Form and Instruction
Coccidioidomycosis Case Report Form Att 3b- Coccidioidomycosis Case Report Form.docx	Form and Instruction
Coccidioidomycosis Case Report Form Att 3b- Coccidioidomycosis Case Report Form.docx	Form and Instruction
Coccidioidomycosis Case Report Form rev Att 3b- Coccidioidomycosis Case Report Form.docx	Form and Instruction

IC Title:

Coccidioidomycosis Case Report Form

Agency IC Tracking Number:

0920-1385

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Coccidioidomycosis Case Report Form	Att 3b- Coccidioidomycosis Case Report Form.docx		Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Coccidioidomycosis Case Report Form rev	Att 3b- Coccidioidomycosis Case Report Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.